Admission Application Application Form There is no fee to apply and no deposit required. You will receive an email confirmation of your submission. Application Potential Resident Information:PrefixName(Required) First Last Preferred Name First Birth DateMarital StatusCurrent Address Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code Person completing this form:Name First Last RelationshipAddress Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code Your Email Address(Required) Email Address Confirm Email Address Your PhonePotential Resident Information:Does the person have a memory problem? Yes No If Yes, for how long?Has this condition been evaluated? Yes No If Yes, evaluation was performed by:DiagnosisPersonal Care PhysicianOther Medical DiagnosisCurrent MedicationsPrimary CaregiverRelationshipWhat are the current living arrangements? Independently at home With family At a care facility If at a care facility, where?What supportive services are provided?Describe the person's cognitive abilities in the following areas:MemoryJudgementLanguageResponsive to requests / instructionsDescribe the amount of assistance required in the following activities:e.g., independent, cueing required, assistance, total assistanceDressingMealtimesCurrently on special diet ordered by physician? Chopped Fine chopped Puree Thickened liquids? Yes No BathingToiletingIs the person continent? Yes No If NO, please describe assistance requiredAble to walk independently? Yes No Requires Assistance Assistive devices used? Cane Walker Wheelchair Is the person diabetic? Yes No How is it managed? Insulin injections Diet Other Does the person wander?e.g., paces, “wants to go home”, times most likely to wander, etc.Describe any challenging behaviors?e.g., verbally/physically aggressive, resistive to care, etc.Sleep habits or problems?Describe the person's personality before the illness and today:The following words may be helpful: content, extrovert, friendly, happy, independent, introvert, reserved, sad, serious, suspicious, timidPersonality before the illnessPersonality todayDescribe a typical day for this personDescribe a typical night for this personPower of AttorneyHas a durable medical power of attorney been designated? Yes No NamePhoneHas a durable financial power of attorney been designated? Yes No NamePhoneHas an advance directive or living will been completed? Yes No Which location is preferred? Bayside Nu'uanu Pali First Available What type of room is preferred? Semi-Private Private Either How soon is placement desired? 1-2 months 3-6 months 6 months or longer How did you hear about Hale Kū‘ike?PhysicianFriend / FamilyReferral agencyOnline SearchTV adOtherIf Other, please describe: View Our Locations Pali Bayside Nu‘uanu
